Maternal mental health in Nepal and its prioritization during COVID-19 pandemic: Missing the obvious

Dear Sir,

COVID-19 pandemic has taken a toll on all health services and reproductive health has also been bearing its brunt. There should be no divided opinion that psychiatry is related to COVID-19 and more so in Asian countries due to their political and economic vulnerabilities (Tandon, 2020). Under-prioritization of womens’ psychiatric issue at these times would be missing the obvious. Nepal has a high maternal mortality ratio of 239 deaths per 100,000 live births (NDHS, 2017), due to which safe motherhood, contraception and abortion have always been a priority despite having an impoverished health system. On the other hand, mental health issues of women which is also burgeoning but under-acclaimed problem, is under-researched and grossly overlooked (Regmee et al., 2015). Reproductive health and mental health are interwoven and a complete well being cannot be obtained without their integration.

The first witnessed COVID related death in Nepal was a young woman in her postpartum period and this has paramountly increased the stress that millions of pregnant women are currently facing. Mental health in pregnancy and puerperium is not addressed to the extent of its necessity and this pandemic has increased the ever present gap in maternal mental health issues.

Nepal has just above 57 % institutional deliveries and this pandemic may force women to go back to unskilled birth providers increasing maternal morbidity and mortality (NDHS, 2017). Most hospitals have been recommending women to delay their regular antenatal visits as a public health measure to contain virus spread. Without meeting their health provider in person, a complete antenatal package including mode of delivery cannot be decided. Lack of counseling, uncertainty and indecisiveness increases stress during pregnancy. In addition to this, pregnant women are worrying about COVID19 effects on their health and their newborns. The SARS and MERS epidemics had profound effect on mental wellbeing of pregnant women more because complications like miscarriages were seen with these infections (Lee et al., 2006). Though limited studies in small cohorts have shown no vertical transmission of COVID19, results of long term studies regarding teratogenicity and other possible effects are yet to be published (Schwartz and Graham, 2020).This paucity of literature and evidence of COVID-19 impact on new born, makes it difficult for service providers to reassure patients about their concerns regarding newborn health outcomes, which adds to their psychological distress.

Mental health issues of health service providers are also important. There are many pregnant and postpartum staff working in COVID hospitals and with news of few succumbing to the infection during work, has caused fear and stress amongst them (“Pregnant Algeria doctor”, 2020).

Stress during this pandemic continues from pregnancy to postpartum. Persistent psychological distress and worries in pregnancy can be counter-productive and predispose to post partum depression and post partum psychosis. Nepal has high mortality among 15–45 years age group due to suicide and one reason for this is post partum depression (Simkhada et al., 2015). Since postpartum services are also hampered at these times postpartum women may get suboptimal care. Early discharge is not possible due to travel bans. Prolonged hospital stay, financial burdens and difficulties to commute to their home during lockdown also adds to postpartum stress which may predispose suicidal tendencies.

Sharing responsibilities in the household is a major pillar for preventing postpartum stress and having a partner for postpartum care and breastfeeding reduces the mental burden on the new mother. In Nepal, many women are wives of migrant workers and live with depression (Aryal et al., 2019). They are left with no support at home because their husbands are not able to return home due to lock down. Anticipation about their husband health status abroad is another reason for their anxiety. On the other hand, some migrant workers have been forced to return to their countries and this has increased the need for contraception in women which includes postpartum contraceptive measures. Obstetric wards are underprepared during these times (Chua et al., 2020) and these services are also not running effectively at present in all health facilities. In absence of contraceptive services, women are unable to make informed choices regarding spacing of pregnancy which adds to their many postpartum difficulties.Another reason for mental overburden is the household chores. In a stereotypical Nepali culture, pregnant or post partum women are over burdened due to increased household demand. Domestic abuse, gender based violence specially intimate partner violence is on the rise during this pandemic (Taub, 2020), which increases pregnancy complications both mental and physical.

Screening for maternal mental health issues is a low priority in Nepal and addressing this issue should be a priority now than ever before. When the focus is in COVID positive cases, policies to detect early signs of mental illnesses which are increasing in non COVID women also have to be formulated. Culturally validated screening tools can be used for all antenatal care packages, and question on suicidality must be accessed. A liaison plan should be made with the involvement of mental health service providers to identify antenatal and postnatal psychiatric issues during hospital stay.

Video conferencing for antenatal care and tele-psychiatry can be a cost effective method for screening, evaluation and management of pregnancy in Nepalese context, where there is scarcity of health professionals. But these may not always be feasible due to low literacy rate especially in rural areas. Mobilization of Female Community Health Volunteers at the community level, to detect pregnancy at risk including mental illness can be continued while maintaining rules of physical distancing.

Obstetrics is one clinical subject where continuity of care is inevitable. Pregnancy and labor cannot wait and along with this comes mental health care. This is the time when women need to exercise their reproductive rights more than ever before and obstetric service providers play a pivotal role in ascertaining that they are able to do so. We need to make sure that these women go through a pleasant birth experience through the integration of physical and mental health. The crisis may always remain, so living with it with essential precautions, innovations and improvisations is the only option.

Financial disclosers

None.

Declaration of Competing Interest

The authors declare that there are no conflict of interest.